This month: What is going on?

For this writer, the papers in this month’s issue present one puzzle after another. Therein lies their enjoyment. Surely, it is very hard to explain why the ubiquitous expansion that has taken place in mental health services, with a major increase in the personnel, expenditure and use of medication, has brought no drop in the prevalence of common mental disorders. Earlier this year, Jorm et al. (2017) drew the world’s attention to this disappointing fact. What is going on to bring it about? We can only speculate. Now, Mulder et al. (this issue) take the matter further. They ask if action needs to be taken outside the domain of traditional clinical practice, directed at preventing the onset of these syndromes, at human living conditions and even that complex entity called lifestyle. Mental disorders are recognised as a major part of the overall burden on health (Whiteford et al., 2013). Indeed, Lee et al. (this issue) estimate that the treatment of these disorders in Australia costs almost $1 billion a year. In the last 20 years, the use of psychotropic medication in Australian women has increased fourfold (Stuart et al., this issue). Bear in mind that the expenditure of $1 billion is reaching only a half of all the cases that epidemiological studies say exist, because most people with mental illness are not treated (Thornicroft, 2007). Furthermore, that $1 billion does not include the cost of the psychoses. This is a situation that calls for hard thinking by a diversity of experts. The ANZJP would welcome views on how to move forward. Making unwell people better is why we are here.

One highly efficient treatment for the common mental disorders is said to be online psychotherapy (Titov et al., this issue). There is now emerging evidence that it works for anxiety and depression, at least for prevention of these disorders, is strikingly inexpensive, conserves highly trained personnel and is both accessible and acceptable to users who often would otherwise not be in contact with services. Further research into assessing its potential benefits is needed, following which its further uptake should to be considered – noting that it may simply join the many other treatments that ultimately prove to be impotent at the population level.

In a highly significant paper, Sedgwick et al. (this issue) have identified, with what seems to be remarkable precision, the main neuropsychological abnormalities associated with violence in persons with schizophrenia or antisocial personality disorder. Memory defects and temporo-limbic dysfunction emerge as central. Importantly, these same impairments make such people less able to participate in and benefit from psychological therapies. Here is new knowledge that makes it all the more pressing to find treatment and prevention.

For better or for worse, psychiatry keeps adding new syndromes to its lexicon, each being given a new name. A recent arrival is disruptive mood dysregulation disorder. Perich et al. (this issue) have looked for states of mood dysregulation in 242 people at increased risk of bipolar disorder because of their family history. Unlike previous reports, they found not a single individual fitted the criteria set out in Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) for disruptive mood dysregulation disorder or severe mood dysregulation. They conclude that mood dysregulation and chronic irritability are not good predictors of subsequently developing bipolar disorder. So, what is going on in the brains of young people who have mood dysregulation and what does it lead to over time? Reciprocally, what are the childhood precursors of bipolar disorder? Here is an example of how research findings, including negative ones such as this, can lead to better specified hypotheses. Insofar as there are neurodevelopmental abnormalities in bipolar disorder, and that close relatives may show some of these, the use of pluripotent stem cells derived from them promises to throw light on what may be going on at the molecular level. The use of stem cells in psychiatric research is a field to watch. In a further instance of striving towards a finer-grained classification is a proposal that ‘obesity dysmorphia’ be included in the DSM. Russell (this issue) gives evidence why this may be phenomenologically inappropriate. She argues that patients who show the features of this proposed entity may have an atypical depression or an addictive disorder, so there is no need to create another syndrome.

On the deeply concerning issue of suicide in Australian Indigenous people, Armstrong et al. (this issue) have used data from the remarkable Australian Longitudinal Study on Male Health, which involves almost 16,000 persons. They find a very sharp rise in the risk of suicide for young Indigenous males as they enter adulthood. What is going on to bring this about? Any period in life characterised by rapid rise in risk is very much an opportunity for intervention. One should bear in mind that it is not necessary to have a full understanding of aetiology to have successful intervention (Eisenberg, 1962). The gravity of Armstrong et al.’s finding is not tempered by the fact that the study had a response fraction of only 35%, so we do not know about the other 65%. Non-responders may well have had even higher morbidity and disadvantaged lives. Furthermore, the study could not cover remote communities for very practical reasons, yet these are known to have particularly high mortality.

We believe there is a place in our pages for more than the immediacies of psychiatry and clinical practice. For many, being aware of the ‘complexities of human interaction’ leads to our finding great fulfilment from other domains, not least from the literature. Most of us are treading a path largely unforeseen when we started medical school. In his hope that something of the mental life of Renaissance scholars might regain a place in our lives, Kaufman (this issue) thinks that it was ‘the love of knowledge’ (his words) that took many of us to medical school when we were still fuelled by the idealism of youth. For him, the wider education he received reading medicine at Columbia University led him to have a much fuller life as a doctor and person. His first paragraph says things this writer unreservedly endorses, even if it does not apply to us all. He says our humanism and scientific literacy can be enhanced by sampling the works of some of the great writers. Here is an example. Any registrar who wants to understand morbid jealousy will do well to read Tolstoy’s ‘The Kreutzer Sonata’. But in doing so, that trainee will also encounter some exquisitely delicate ideas lying quite outside the immediate topic and will thenceforth be better equipped to write well.

And finally, The Psychiatry Ashes. Our Editor has come up with something really innovative. He has struck a deal with his counterpart in the British Journal of Psychiatry whereby 11 Australian and 11 UK psychiatrists will compete according to defined criteria for performance. This is an exceptionally attractive idea, infused with both the advancement of scholarship and humour. Let us hope that Gin Malhi himself enjoys attending every match! Many will certainly do so, in both countries.